Chronic Pain and the Opioid Shadow

Thirty-six percent of Americans over 65 report chronic pain, meaning pain on most days or every day for three months or more. Among those, more than one in three say the pain limits their daily activities. These figures, from the CDC’s most recent National Health Interview Survey, describe a condition so common among older adults that it has become background noise in a healthcare system that has never quite figured out what to do about it.

The system has, however, figured out how to make the problem worse. Twice.

How Pain Management Went Wrong

The story is by now familiar in its broad strokes, but its details matter because they are still shaping what happens in examination rooms today.

In the late 1990s, pain became the “fifth vital sign.” Pharmaceutical companies, most notoriously Purdue Pharma, marketed opioids as safe and effective for chronic non-cancer pain. Doctors were told they were undertreating pain. They were told that addiction risk was minimal. They prescribed accordingly. Between 1999 and 2012, opioid prescriptions in the United States nearly tripled. Older adults, who carry the highest burden of chronic pain, received a disproportionate share. In many cases, medications designed for acute post-surgical pain were prescribed for years, even decades, to manage conditions like osteoarthritis and degenerative disc disease.

The consequences were devastating. Falls increased. Cognitive impairment worsened. Constipation, a seemingly minor side effect, cascaded into bowel obstructions, hospitalizations, and a secondary medication burden. Respiratory depression killed people in their sleep. By the mid-2010s, opioid overdose had become a public health emergency.

Then came the correction. The CDC’s 2016 prescribing guidelines recommended non-opioid therapies as first-line treatment for chronic pain. The guidelines were intended as clinical recommendations, not rigid mandates. But insurers, pharmacies, state legislatures, and physicians treated them as hard limits. Patients who had been on stable opioid doses for years had prescriptions cut abruptly. Some were dismissed by practices unwilling to manage opioid patients. Others were tapered too quickly, producing withdrawal symptoms their doctors did not always recognize.

The CDC acknowledged the damage. Its 2022 revised guidelines stated that the original recommendations had been misapplied through “rapid opioid tapers and abrupt discontinuation without collaboration with patients” and “patient dismissal and abandonment,” contributing to “untreated and undertreated pain, serious withdrawal symptoms, psychological distress, overdose, and suicidal ideation.”

What Chronic Pain Actually Is

To understand why pain management is so difficult in older adults, it helps to understand what chronic pain is and what it is not.

Acute pain is a warning signal. Touch a hot stove and the nervous system fires an alarm that makes you pull your hand away. The pain is proportional to the injury, and it resolves as the tissue heals. Chronic pain is something different. After three to six months of sustained signaling, the nervous system itself changes. Nerve pathways become sensitized. The brain’s pain processing centers reorganize. Pain persists not because the original injury is still sending signals, but because the nervous system has learned to generate pain on its own.

This process, called central sensitization, is why chronic pain is increasingly understood not as a symptom of another condition but as a disease of the nervous system in its own right. It is also why simply treating the original source, replacing the arthritic knee, fusing the damaged disc, is sometimes not enough. The pain has migrated from the joint to the wiring.

Older adults are more vulnerable to this process for several reasons. Inflammatory markers increase with age, priming the nervous system for pain amplification. Sleep disruption, nearly universal in older adults with chronic pain, interferes with the body’s overnight pain modulation. Depression and anxiety lower pain thresholds. These are not separate problems. They form a self-reinforcing cycle: pain disrupts sleep, poor sleep worsens pain, worsened pain feeds depression, depression amplifies pain.

Breaking that cycle requires treating all of it, not just the part that shows up on an X-ray.

Margaret’s Story

Margaret is 76. She has osteoarthritis in both knees and degenerative disc disease in her lumbar spine. For six years, her doctor managed her pain with OxyContin, and she functioned. She gardened. She drove. She hosted her grandchildren.

Then her doctor retired. Her new physician, trained during the peak of opioid scrutiny, cut her prescription by 75 percent over three months. She spent a year in a fog: sweating, restless legs, insomnia, anxiety so severe she stopped leaving the house. Nobody told her she was experiencing opioid withdrawal. When the fog lifted, the pain was worse than before she had ever taken the medication.

Now she takes ibuprofen twice a day. It is damaging her kidneys. She uses a heating pad. Nobody has mentioned physical therapy, cognitive behavioral therapy for chronic pain, nerve stimulation, or structured exercise. She was handed a problem she did not create and left to manage it with tools that are making other things worse.

Margaret’s experience is not unusual. It is the norm. And it reveals the central failure of American pain care for older adults: the system swings between extremes instead of holding the difficult middle ground.

The Opioid Question, Honestly

Neither demonizing nor defending opioid use in older adults serves the people living with pain. The honest evidence is more complicated than either camp allows.

Some older adults with chronic pain benefit from carefully managed, long-term opioid therapy. Stable, low-dose regimens can maintain function and quality of life in patients who have been thoroughly evaluated and regularly monitored. The risks are real: increased fall risk, cognitive cloudiness, respiratory depression, constipation severe enough to require its own treatment. But for patients who have tried other approaches and found them inadequate, a carefully supervised opioid regimen may be the least harmful option available.

The problem is not opioids themselves. It is the absence of infrastructure around them. A patient on long-term opioids needs regular reassessment, fall risk evaluation, periodic attempts at dose reduction, and access to complementary therapies. In an eight-minute primary care visit, none of that happens.

Deprescribing is equally complex. A person on opioids for years has a nervous system that has adapted to the medication. Stopping abruptly produces withdrawal that is not only miserable but medically dangerous in older adults: elevated blood pressure, cardiac stress, falls. Safe tapering can take months, sometimes years, with frequent contact and dose flexibility that the system does not reward.

What Works Instead (and What Does Not)

The phrase “multimodal pain care” appears in every guideline and almost no clinical realities. It means combining several approaches to address different components of the pain experience. The evidence for many of these approaches in older adults is strong. The access is not.

Physical therapy, specifically graded activity and pain neuroscience education, is among the most effective treatments for chronic musculoskeletal pain. It works by gradually reconditioning the body and teaching patients how pain actually functions, reducing the fear-avoidance behaviors that worsen disability. Cognitive behavioral therapy for chronic pain (CBT-CP) has strong trial evidence showing reduced pain severity and decreased medication reliance. Mindfulness-based stress reduction shows similar benefits. Both are scarce, rarely covered adequately by insurance, and virtually unavailable in rural areas.

Nerve stimulation, both transcutaneous and implanted, offers benefit for certain pain types. Joint injections and nerve blocks can provide months of relief for specific conditions. These are tools, not miracles, and they work best as part of a broader plan.

One genuinely new development: suzetrigine (Journavx), approved by the FDA in January 2025, is the first drug in a new class that blocks pain signals at the peripheral nerves without opioid addiction risk or the gastrointestinal, renal, and cardiovascular damage of long-term NSAID use. It is currently approved for acute pain. Its role in chronic pain management for older adults is still being defined, but it represents what a real non-opioid pharmaceutical advance looks like, as opposed to the vague suggestion to “try something else” that too many patients receive.

A note of caution: most supplements marketed for chronic pain lack meaningful evidence. Unregulated CBD products vary wildly in composition. Regenerative medicine (PRP, stem cell injections) has limited evidence for most applications despite aggressive marketing. The gap between what is sold and what is supported by evidence remains wide.

The Access Problem

Multimodal pain care is the standard of care in guidelines. It is the exception in practice. The gap between what the evidence supports and what most older Americans can actually access is among the widest in American medicine.

The geography of this gap matters. Rural Americans over 55 have consistently higher rates of chronic pain than their urban counterparts, and the gap has widened over two decades. These are also the communities with the fewest pain specialists and the longest drives to interventional care.

The racial dimension is equally stark. Black Americans are systematically undertreated for pain, a finding replicated across dozens of studies over three decades. Black patients are less likely to be prescribed pain medication, receive lower doses when they are, and face greater scrutiny for opioid prescriptions. A landmark 2016 study found that half of white medical students and residents endorsed false beliefs about biological differences between Black and white people, including that Black people have thicker skin, and these beliefs directly predicted less accurate treatment recommendations.

The opioid overcorrection compounded these disparities. When prescribing became more restrictive, the restrictions fell most heavily on the patients already receiving the least adequate care.

The ACCESS model, the CMS innovation launching in July 2026, may begin to address some of these failures. Its coverage of chronic pain management through remote monitoring and tech-enabled care could expand access for people who cannot easily travel to specialized pain clinics. But technology alone does not fix the underlying shortage of pain specialists, the inadequate insurance coverage for physical therapy and pain psychology, or the implicit biases that shape who receives what care.

For the Person Who Hurts Every Day

If you are living with chronic pain and have stopped believing anyone can help, the problem is not your pessimism. It is a rational response to a system that has let you down. But the system’s failures do not mean that nothing works.

Ask for a referral to a pain specialist who practices multimodal care rather than relying solely on procedures or prescriptions. If you are on opioids, do not let anyone take them away abruptly; the 2022 CDC guidelines explicitly state that tapering should be gradual and collaborative. If you have never tried physical therapy specifically designed for chronic pain, the approach is different from post-surgical rehab and often more effective than any single medication.

Ask about your sleep. Ask about your mood. Not because the pain is in your head, but because sleep, mood, and pain share neural circuitry, and treating one genuinely helps the others.

The pain you are carrying is real. It is not your fault. And the body that hurts at 76 is still a body that can feel better, even if “better” does not mean “cured.” The difference between suffering alone with pain and living with pain alongside the right support is enormous. That support exists. The work is finding it.